|Year : 2021 | Volume
| Issue : 1 | Page : 31-35
Histomorphology panorama of neoplastic gastrointestinal lesions in a tertiary care center
Sunita Bamanikar1, Dayanand Sonkawade1, Parul Bhandari1, Arvind Bamanikar2, Shirish Chandanwale1, Archana Buch1
1 Department of Pathology, Dr. DY Patil Medical College, Hospital and Research Centre, Dr. DY Patil Vidyapeeth, Pune, Maharashtra, India
2 Department of Medicine, Dr. DY Patil Medical College, Hospital and Research Centre, Dr. DY Patil Vidyapeeth, Pune, Maharashtra, India
|Date of Submission||06-Jun-2020|
|Date of Decision||22-Jul-2020|
|Date of Acceptance||07-Aug-2020|
|Date of Web Publication||22-Jan-2021|
5 and 6, Siddharth Estates, North Avenue, Kalyani Nagar, Pune - 411 006, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: Neoplasms of the gastrointestinal tract (GIT) are one of the most common malignancies accounting for 11% of all cancers. There is an increasing burden of GI cancer worldwide, wherein gastric cancer ranks fourth and esophageal cancer ranks the eighth most common cancer. Histopathological confirmation is always necessary for planning appropriate treatment regimen. Hence, in this study, we aim to analyze and correlate with clinical parameters the spectrum of all GI neoplasms encountered in our institute. Materials and Methods: The present study is carried out during 5 years' period of all neoplastic GI specimens received in the department of pathology. Results: Of the total 259 biopsy and excised specimens from neoplastic cases, benign were 14 (5.4%) and malignant lesions were 245 (94.6%) with adenocarcinoma being the most common histotype. The frequency of male was marginally higher with M:F ratio of 1.1:1 was observed in all GI diseases with exception of gall bladder which revealed female predominance. The mean age of patients was 55.2 years. Colorectal carcinoma was more commonly observed (40.5%) than esophageal squamous cell carcinoma (27.4%). Conclusion: Neoplasm of the colorectal region was the most common followed by esophagus tumors. The most common age group affected was 51–60 years. With an increasing incidence of neoplastic lesion in GIT, prevalence and mortality of the disease can be minimized with early detection of lesion, histopathological examination being gold standard.
Keywords: Adenocarcinoma, gastrointestinal neoplasms, squamous cell carcinoma
|How to cite this article:|
Bamanikar S, Sonkawade D, Bhandari P, Bamanikar A, Chandanwale S, Buch A. Histomorphology panorama of neoplastic gastrointestinal lesions in a tertiary care center. Med J DY Patil Vidyapeeth 2021;14:31-5
|How to cite this URL:|
Bamanikar S, Sonkawade D, Bhandari P, Bamanikar A, Chandanwale S, Buch A. Histomorphology panorama of neoplastic gastrointestinal lesions in a tertiary care center. Med J DY Patil Vidyapeeth [serial online] 2021 [cited 2021 Feb 27];14:31-5. Available from: https://www.mjdrdypv.org/text.asp?2021/14/1/31/307665
| Introduction|| |
Cancer is a major public health problem worldwide, with almost one in every four deaths. India is harboring 0.31% of cancerous conditions worldwide, where colorectal carcinomas account for 4th most common cancer affecting 0.03% population of the world while gastric cancers comes 8th in rank affecting 0.01% of the world population. Overall, the gastrointestinal (GI) cancers are responsible for more cancers and more deaths from cancer than any other cancers.
Progression of malignant lesions to distant metastasis is a major cause of cancer-related mortality in adult population. With ongoing demographic and epidemiological transition, cancer has emerged as a major public health concern in Indian population. Fourth leading cause of cancer related mortality is of gastrointestinal tract (GIT) tumors worldwide with 4th most common being gastric carcinoma followed by 8th esophageal carcinoma.
With advancement in medical technology, the minimal invasive procedure such as endoscopy and colonoscopy followed by biopsy, along with radiological correlation always plays a crucial role in definitive diagnosis. Any consistent inflammation or irritation in GIT can lead to precancerous conditions from dysplasia to neoplasia. The definitive diagnosis of GI lesions depends on the histopathological confirmation which is needed for initiation of treatment.
Hence, this study is conducted to evaluate the spectrum of all neoplastic lesions of GIT and to correlate the histopathological findings with age, sex, and other clinicopathologic parameters.
| Materials and Methods|| |
This unicentric, observational study was conducted over a period of 5 years from January 2015 to December 2019; in the Department of Pathology, Dr. DY Patil Medical College, Hospital and Research Centre, Pune, India. The study was approved by the Institute Ethics Committee (Letter number DPU/RandR/(M)/2018 dated January 12, 2018).
A total of 259 GI biopsy and excised specimens were evaluated of which 121 cases were retrospective. Complete clinical history was obtained from the department records for histopathological correlation. Endoscopic and radiological findings were noted whenever available. All tumors of upper and lower GIT, of all ages and both sexes were included in the study. Autolysed specimens were excluded.
Specimens for the prospective period were received in 10% buffered formalin, were fixed for 12 h; followed by grossing and sections were taken from appropriate lesions. Sections were processed in an automated tissue processor; multiple sections of approximately 5 μm thick were cut with microtome and stained with routine hematoxylin and eosin stain. For the retrospective study, paraffin blocks of specimen were retrieved and processed. The sections were then examined under the light microscope, the lesions were diagnosed as benign, malignant, and classified according to the recent WHO classification. Special stains including immunohistochemical stains were applied whenever required.
Results were then tabulated and statistically analyzed.
| Results|| |
A total of 4758 specimens were examined from GI lesions over a period of 5 years, of which 259 were neoplastic (5.44%) with increased prevalence of malignant lesions (94.6%) on histopathological examination. Majority were males 138 (53.2%) followed by 121 (46.8%) female cases with M:F ratio of 1.1:1. The mean age was 55.2 years with youngest patient being 26 years of age having gastric GI stromal tumor (GIST) and the oldest was 76-year male having rectal adenocarcinoma. The most common age group affected was 51–60 years with 80 cases (30.8%) followed by 41–50 years of age group with 62 cases (23.9%); however, anorectal lesions mostly affected the older groups 41–70 years [Table 1].
|Table 1: Age group and organ.wise distribution of neoplastic cases (n=259)|
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Of total 259 neoplastic specimens, 94.6% were malignant followed by 5.4% benign. Among benign lesions hyperplastic polyp was most common histotype. Large intestine and anorectum were most commonly affected 40.5% among neoplastic lesion followed by esophagus (27.4%) and stomach (24.4%) [Table 2].
Among 245 malignant cases, adenocarcinoma accounting 62% was most common, followed by squamous cell carcinoma (30.2%) with esophagus being mostly affected [Figure 1]. The incidence of malignant GIST was 5.4%, were positive for CD117 immunohistochemical stain [Figure 2] and the most commonly affected site was stomach (2.4%). Least common was malignant lymphoma and leiomyosarcoma with 0.4% each [Table 3].
|Figure 1: Microphotograph of esophageal well-differentiated squamous cell carcinoma (H and E, ×100). (a) Squamous cell carcinoma of esophagus with keratin pearl (H and E, ×400)|
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|Figure 2: Microphotograph of small intestinal gastrointestinal stromal tumor with intersecting fascicles (H and E, ×100). (a) Shows spindle cells, oval nuclei, pink cytoplasm, and occasional mitosis (H and E, ×400). (b) Shows strong immunoreactivity for CD 117 antibody (Immunohistochemical stain, ×400)|
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|Table 3: Distribution of malignant lesions according to histopathological type (n=245)|
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The most common type of histological differentiation seen overall was moderately differentiated variant in both adenocarcinoma and squamous cell carcinoma (50%) [Table 4].
|Table 4: Distribution of carcinomas according to histopathological differentiation (n=226)|
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| Discussion|| |
In the present study, from January 2015 to December 2019, it has been observed that the frequency of neoplastic lesion was on increasing trend with 40, 44, 53, 58, 64 cases occurring in each year, respectively. Highest incidence of neoplastic lesion was observed in 5th decade age group, similar age distribution trend was observed by Khatib et al. and Prabhakar et al. However, the 2nd most affected age group was in 6th decade which is similar to study done by Parikh and Parikh The gender-wise distribution shows slight male predominance which reflects male population is more exposed to risk factors than females. In contrast, gall bladder cancer shows female predominance with 2–6 times more than in males.
The most common malignant lesion of esophagus is squamous cell carcinoma seen in middle and lower part of esophagus whereas gastroesophageal junctions were mostly affected by adenocarcinoma with co-existent intestinal metaplasia. In the present study, 70 cases (27.4%) of esophageal squamous cell carcinoma were seen with middle and lower esophagus being most commonly affected, which is similar to study reported in literature by Sabharwal et al. [Table 5].
|Table 5: Comparison of organ-wise distribution of gastrointestinal tract malignancies|
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Adenocarcinoma was the most common malignancy seen in stomach followed by lymphoma which accounted for 3%–5% of all gastric malignant tumors. These findings partly correlate with the observation in our study where gastric adenocarcinoma is the most common (21.1%), followed by malignant GIST with 2.4%. This incidence is similar in literature where GISTs account for approximately 2% of all malignant gastric tumors. Similar observations [Table 5] have been reported in studies done by Parikh and Parikh In studies reported in literature, tubular adenocarcinoma is the most common however, in our study, diffuse variant [Figure 3] was most common (56.8%) followed by tubular (43.2%), this finding concords with study done by Qui et al. In our study, the least common was gastric lymphoma (0.4%); this variation may be because of low incidence of overall GI lymphoma in the present study.
|Figure 3: Microphotograph showing metastatic deposits of signet ring cells in subcapsular sinus (arrow) of lymph node (H and E, ×100). (a) Signet ring showing periodic acid–Schiff positivity (periodic acid–Schiff, ×400). (b) Signet ring with mucicarmine positive (MUC, ×400)|
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We encountered six cases (3.1%) of adenocarcinoma and a rare case of adenosquamous carcinoma (0.4%) of gall bladder; it is a rare histological subtype accounting for 1%–5% of gall bladder carcinomas. The incidence of gall bladder carcinoma in our study correlates well with study reported by Shreshtha et al.
The incidence of small intestine carcinoma is less in spite of its longer length and adenocarcinoma is its most common histiotype. In the present study, we encountered 8 cases (3%) of adenocarcinoma with 1st part of duodenum being most commonly affected.
Neoplastic lesions of appendix are rarely seen which may be found incidentally after appendectomy performed. Carcinoid is the most common tumor in appendix followed by adenoma and lymphoma, the incidence of adenocarcinoma being 0.08% of all cancers and 0.5% of all GI cancers. In the present study, we encountered two cases of adenocarcinoma of appendix (0.8%), which is slightly higher than reported in literature [Figure 4].
|Figure 4: Microphotograph of appendix showing mucin secreting adenocarcinoma infiltrating the muscle layer (H and E, ×400)|
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Colorectal cancer (CRC) is a substantial public health burden, and it is increasingly affecting populations in Asian countries. However, the overall prevalence of CRC is reported to be low in Asia when compared with that in Western nations. In our study, most commonly affected site for neoplastic lesion was colon-rectum (40.5%) and CRC occurred with highest frequency (37.1%) as also in a study documented by Sabharwal et al. CRC is the fourth most frequent cancer, where adenocarcinoma is most common, squamous cell carcinoma (SCC) of colon is a rare feature, and only <100 cases have been reported in the literature. SCC of the colon without known primary source is a rare finding which needs aggressive management with prime location in recto-sigmoid colon. In the present study, one case of recto-sigmoid SCC was seen. In literature, studies reported by Ekta et al., and Parikh and Parikh concord with incidence of colorectal adenocarcinoma in our study. Small intestinal malignancies were least common in all studies, in our study, appendicular malignancy was least common [Table 5].
Lymphoma can occur in any part of the GIT, most common sites being stomach followed by small intestine and ileocecal region. We encountered one case of primary non-Hodgkin's lymphoma, one case of malignant melanoma and one case of leiomyosarcoma in our study. Primary GI sarcomas are rare accounting for 1%–2% of GI malignancies; of this, leiomyosarcoma is the most common histotype with high malignant potential, mainly seen in the fifth and sixth decades of life.
| Conclusion|| |
GI tumors show a wide variation in morphology with increase prevalence of malignant tumors; hence, histopathological examination with immunohistochemical investigation whenever necessary; is gold standard for the diagnosis and typing of these tumors, for appropriate treatment of various GI malignancies. Colorectum was the most commonly involved site, mostly affecting the 41–70-year age group and overall adenocarcinoma was the most frequent histotype followed by SCC. Moderately differentiated variant was the most common histological differentiation in all carcinomas.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]